Thursday, 26 July 2012

Community health at its best.

The Joint Committee on Vaccination have recommended that all children aged between 2 and 17 years are to be offered free flu vaccines. It is estimated that if 30% parents opt to vaccinate their children via a nasal spray, this will save 2,000 lives a year and avoid 11,000 hospitalisations.

Although flu tends to be a nuisance for the young, it is rarely fatal. However ‘coughs and sneezes spread diseases’ and children are not known for efficient infection control. As carriers of a nasty flu bug, they can infect the more vulnerable in society and flu can be a killer for the elderly, diabetics, pregnant women and other at-risk sections of the community, young and old, such as asthmatics.

The vaccine is administered as a painless nasal spray, so in theory should cause little or no discomfort to the recipient. So it’s a no brainer – yes? As with any health initiative there are pros and cons. The pro’s as listed above are real and significant. The cons would include cost - £100 million to vaccinate the 9 million eligible children each year. This must surely be covered by the £millions saved by reduced flu-related hospital admissions and death. A more challenging issue would be the manpower to administer such a radical programme – hospital nurses in many schools are either non-existent or already fully stretched. This is a good opportunity to review the entire vaccination programme in the UK with a possible benefit of releasing additional GP time by training up more ‘vaccination professionals’ such as nurses and paramedics. The strongest ‘anti’ vote will be from parents who feel that their children are overloaded with preventative measures and their fears for the safety of some vaccines – the hoo hah over the MMR and HPV vaccine is testament to this. As this is an annual vaccine, the decision may be even tougher.

So why should a parent allow their child to be vaccinated against flu each year? The same reason that I believe they should allow their children to be vaccinated against other diseases and health threats such as Rubella, Mumps, TB and the HPV virus. Not just for their child’s sake – but for the common good.

Herd immunity is a highly positive phenomenon. By vaccinating most individuals, others, some not even yet born, automatically benefit from reduced exposure to a disease. The HPV vaccine is an excellent example of this. Since its introduction in 2008, 80% of eligible girls have been protected against the virus, which is directly linked to cervical cancer. If ALL eligible girls in the UK were vaccinated it is highly likely that cervical cancer in the UK could virtually be eradicated. Fantastic. Except that some schools are refusing to offer the vaccine based on ‘Christian principles’.

I would like to live in a world where any ‘principle’ of behaviour includes consideration not for just self but the wider community. I know that annual flu vaccines of children won’t eradicate this potentially major cause of death and serious illness, but if it can save at least 2,000 lives each year surely this is a worthy aim?

These are just the type of initiatives we need to see more of to secure better health levels and reduced healthcare costs for the next generation. Targeted vaccination programmes are not just about the individual, they impact the community in which they live. This isn’t about a ‘nanny state’ – it’s about collective responsibility.

Tuesday, 17 July 2012

Good care doesn't have to be complicated.

The tragic case of Kane Gorny is a dramatic example of what can and does, go wrong in a hospital ward. Kane was just 22 when he of dehydration in a London hospital. He was so desperate for fluids and so upset that the hospital staff ignored his pleas that he dialled 999 and called the police who took his call seriously enough to come to the hospital ward to find out what was going on. They were sent away by the staff and Kane later died, for lack of water.

The case isn’t as straightforward as it would first seem, that patients were dying in the NHS simply for the want of a drink of water. This unfortunate young man was suffering from a medical condition which meant that he needed regular medication and constant top up of fluids to ensure that his organs received the hydration they needed. Add into the mix that Kane had suffered a brain tumour a year earlier which meant he could be prone to bouts of aggression. None of this was unmanageable and his post-surgery care after a hip operation should have been routine as long as the staff responsible for his care understood his medical history and specific needs.

The coroner investigating Kane’s death ruled that he was ‘undoubtedly let down by incompetence of staff, poor communication, lack of leadership, both medical and nursing, …a culture of assumption’

It is truly shocking that the many clinical and support staff who came into contact with Kane failed to ascertain the exact needs of their patient. Why was this? Because they didn’t care? I hope not. Because they were too busy? Maybe. Or because there was insufficient ownership and unclear responsibilities? More likely.  They all made assumptions regarding his condition and behaviour. Not one person ‘owned’ the wellbeing of this vulnerable young man. The highly desirable side effect of ownership and responsibility is communication, and good communication between clinical staff would have probably have saved his life.

I have just read a synopsis of the 37 page mandate for commissioning laid down as a result of the
Health and Social Care Bill. It talks about ‘improving recovery of illness’ and that the commissioning board will have a role in ‘maintaining or improving performance’. The government is ‘committed to extending the range of choices at every stage of patient care’. Would any one sentence in the 37 page mandate change the outcome for Kane Gorny? I doubt it. I suspect that he wasn’t so much worried about choice. His needs, and the needs of most patients, are pretty basic. Give me the right treatment at the right time with as much kindness and compassion as is humanly possible.

How can we ensure that quality of treatment and care in our hospitals? Through strong management at ward level. Through clearly defined responsibilities. If one person in that ward had personal responsibility for Kane, then hopefully they would have read his notes and made sure that they understood what was needed. And if they didn’t understand any element of his care there would have been other clinicians on hand to answer their questions.

When I worked in hospitals three decades ago there was a system where at the beginning of each shift the ward sister would allocate a number of patients to each nurse. Those patients would be their responsibility for the duration of the shift and the handover to the next shift was also their responsibility. They ‘owned’ those patients. I hope I’m not being na├»ve in believing that this simple method could still work today as long as you have enough qualified nurses on duty at any one time.

Why change basic principles. Good care is cost-effective care. Strong leadership, performance management and sufficient hands-on qualified staff create good care.  It doesn’t need 37 pages to explain that simple fact.

Tuesday, 10 July 2012

A newspaper’s letters page is not the right place to discuss clinical decisions.

For the non – clinical among my readers, the Liverpool Care Pathway for the Dying Patient (LCP) is defined by Marie Curie Palliative Care Institute as a means to ‘ensure that all dying patients and their relatives and carers receive a high standard of care in the last hours and days of their life’. Actually – for the clinical among my readers the definition is, of course, the same.

I have some very personal views on life and death, as we all do. But, as a clinician, interim NHS project manager and healthcare commentator, I also have a professional view. And guess what? They are the same.

I was shocked to read in the Daily Telegraph yesterday that six physicians had chosen to write to the letters page to imply that hospitals are applying the Liverpool Care Pathway inappropriately for patients to ease bed availability and financial pressure. They state that there is ‘no scientific way of predicting death’ (no argument there) but continue ‘other considerations may come into reaching such a decision such as the availability of hospital resources.’

I must confess that as I read this on the train – I gasped out loud, much to the concern of fellow travellers. Basically, it would appear that Professor Millard and his colleagues are suggesting that patients’ deaths are being hastened to free up beds. This is a truly shocking and disturbing accusation. Worthy of the Daily Mail even. They must have been very pleased with the column inches the Telegraph awarded them. Not only was their message printed in the letters page, they got front page billing (under Andy Muuray’s Wimbledon defeat of course)

What these physicians have done is wrong on so many levels. They have written as supporters of The Medical Ethics Alliance, a ‘Christian medical organisation’. As if politics and the media wasn’t enough – they bring religion into it!

The long and the short of it is – death, like birth is a very personal subject. Not everyone wants to die at home. Nobody wants to die in pain. Dying ‘with dignity’ (oh how I hate that phrase) means very different things to different people. But of one thing I am absolutely certain. The majority – no – the VAST majority of clinicians truly want to avoid patient suffering. They want to ease the passage to end of life with as much compassion, professionalism and care as is humanly possible. We talk of a ‘good death’ and trust me, there is such a thing as a good death.

I stumbled on to #nurchat on Twitter and quickly noted the outrage and upset that this letter has caused clinicians. If these doctors feel that that patients are in effect being ‘bumped off’ to free up beds (which I sincerely doubt’) – then they should not be writing to a national newspaper – they should be following the appropriate, official complaints procedure. These irresponsible individuals have probably caused great distress among readers who may start to doubt that their relatives have been given appropriate palliative care.

I applaud those who write to the papers in an attempt to change political opinion. Some of the letters in The Times in the lead up to the Health and Social Care Bill were priceless. But when it comes to clinical decision making - the public press is not an appropriate medium.

Professor Millard et al – shame on you.

Wednesday, 4 July 2012

Association of medical insurance intermediaries summit

I was wearing my private medical insurance (PMI) hat yesterday when I attended the AMII summit held at the Royal college of Physicians in London. Before you click away from this post, please be reassured that this was not about a bunch of brokers bellyaching about commission rates. (Although I must admit that one such gentleman in the audience did embark on a lonely rant about the good old days at one point during a panel discussion)

The presentations and various discussions have been reported in detail in health insurance magazine so I shall just share with you some personal pearls of wisdom gained from the day.

Fergus Walsh, the BBC medical correspondent is definitely my candidate for ‘thinking women’s crumpet of the year award (subsection  healthcare)’. Softly spoken, but authoritative and clearly committed to the cause of improving health knowledge worldwide Fergus was the perfect master of ceremonies. I was particularly interested to learn of his involvement in global healthcare initiatives and his sensitivity in ensuring that his reporting style about often highly emotive subjects is designed to inform but not distress. I shall leave to your imagination the fact that the props that Fergus used for his presentation included a PIP breast implant, some Tamiflu and a bottle of Viagra…

People working with PMI must understand how the NHS works: Regular readers of this blog and my articles in HI magazine know that this is a drum I bang with tedious regularity. I was heartened to note that most of the delegates do have a genuine interest in the Health and Social Care Bill and its implications for their customers and the nation in general. If you are advising your clients on PMI and other private health provision, you really should understand what’s available to them on the state.

We all know that bad lifestyle choices mean that the obesity and lifestyle related diseases are no longer a ticking time bomb but already on slow release detonation. This was touched on in debate and discussion but it’s old news now. That doesn’t mean it should be ignored, quite the opposite, but we no longer need to be told it’s happening.

The Rt Honourable Stephen Dorrell MP is an intelligent, eloquent and impressive individual who appears to have healthcare and the NHS running through his veins. I have heard the Chair of the Health Select Committee speak on several occasions and he talks pragmatic sense. I LOVE that he doesn’t speak in soundbites – ever. Andrew Lansley please note.

Don’t diss the NHS. If you want to sell PMI – don’t knock the NHS. We are still fortunate to have access to a mouth-watering range of healthcare benefits free at the point of delivery and not based on ability to pay. Yes, PMI offers choice, control and flexibility but most of us were born in the NHS and have used its services on many occasions through our lives.

It’s not ‘either or’ – Private medical care must work alongside the state provision. The consensus of formal debate and coffee break chat was that you cannot and should not separate private and public health when planning new PMI products or development of the NHS. It is possible for co-operation for the common good. Really – there is. Careful service design, consensual approach and robust monitoring are the key.

I don’t understand why the new National Director for Patients and Information at the NHS Commissioning Board had ‘cabinet office’ as his slide template. Or that he is a founder of Dr Foster, an information resource often used by the NHS. Probably the less said about that the better…

Circle Partnership is a very interesting organisation. And the managing partner, Mark Aichroth is an impressive individual who described the ‘credo’ of the partnership and spoke with eloquence and apparent honesty regarding the challenges facing the organisation in building new hospitals and partnering with the NHS. One thing no one can deny – the failing Hinchingbrooke hospital has now come top in a patient satisfaction survey less than six months after Circle took it over.

And finally…

Medical insurance intermediaries are good people! Yes – in the good old bad old days health insurance broking was a wheeze. A long boozy lunch with the client, a bit of nifty footwork on commissions and a lot of same old same old used to be fine for all concerned. The clients were happy, insurers happy and the intermediaries were happy too. We have come a long way since then. Most of the intermediaries that I know not only want to do the very best for their clients – they are also genuinely interested in the services on which they advise and the healthcare climate in general. The delegates at yesterday’s event had a tangible thirst not only for the champagne served at the end of the day, but for an understanding of how this industry can move forward and help, not hinder the NHS.